Different clinical characteristics and outcomes of adult hospitalized SARS-CoV-2 pneumonia patients complicated by cardiovascular events during the first, delta and omicron waves of COVID-19.

Background: The effects of SARS-CoV-2 have varied between significant waves of hospitalization. Research question: Are cardiovascular complications different among the first, delta and omicron waves of hospitalized COVID-19 pneumonia patients? Study design and methods: This was a multi-centre retrospective study of patients hospitalized with SARS-CoV-2 pneumonia: 632 were hospitalized during the first wave (March-July 2020), 1013 during the delta wave (September 2020-March 2021), and 323 during the omicron wave (January 2022-July 2022). Patients were stratified by wave and occurrence of cardiovascular events. Results: Among all hospitalized patients with cardiovascular events, patients in the omicron wave were younger (62.4 ± 14 years) than patients in the first wave (67.4 ± 7.8 years) and the delta wave (66.9 ± 12.6 years) and had a higher proportion of non-Hispanic White people than in the first wave (78.6% vs. 61.7%). For COVID-19 patients who suffered from cardiovascular events, the omicron wave patients had significantly higher neutrophil/lymphocyte ratio, white blood cell and platelet counts when compared to the first wave. Omicron wave patients had significantly lower albumin and B-type natriuretic peptide levels (only 5.8% of the first wave and 14.6% of the delta wave) when compared to either the first wave or delta wave patients. In COVID-19 patients who suffered cardiovascular events during hospitalization, mortality rate in the omicron wave (26.8%) was significantly lower than the first wave (48.3%), time to mortality for non-survivors of COVID-19 patients who suffered cardiovascular events was significantly longer in the omicron wave (median 16 days) than in the first wave (median 10 days). Conclusions: Younger and white patients were affected with cardiovascular complications more often by the omicron variant. Despite higher neutrophil/lymphocyte ratio and WBC counts, the omicron patients with cardiovascular events showed lower heart injuries, lower mortality and longer time to mortality for non-survivors when compared to the first and delta waves.

A multi-methods, multi-actor exploration of the benefits and barriers to milk recording on Irish farms using the COM-B model.

Milk recording is a critical tool in dairy farming, providing individual cow information. When used effectively, this data contributes to on-farm productivity, herd health management decisions and supports prudent veterinary prescribing of antimicrobials. Although an industry and government priority, uptake has been relatively slow in Ireland. This multi-methods, three-part study aimed to gain a comprehensive understanding of the benefits to farm performance, and factors driving uptake of milk recording on Irish dairy farms. It involved an economic analysis of N=516 farms from 2008-2019, a workshop with N=26 stakeholders and an online survey of N=197 non-milk-recording farmers. Quantitative and qualitative data were analysed using econometric models and thematic analysis respectively. Results were synthesised using the COM-B model to gain a deeper understanding of what drives the target behaviour. The study revealed that agricultural education, farm location, farm specialisation in dairy and membership of a farmer discussion group were the main factors influencing uptake of milk recording. Milk recording was associated with a €39.04/cow increase in gross margin, a 177.58 litres/cow increase in milk yield and a reduction of 13,450 cells/ml in bulk milk tank somatic cell count readings. Infrastructural constraints, cost, lack of benefits and workload were the most reported perceived barriers to milk recording by farmers. The Behaviour Change Wheel illustrates how to utilise findings and systematically develop future interventions to increase milk recording uptake. This study highlights the importance of a multi-methods approach to agricultural technology adoption and the need for evidence-based methodology when developing behaviour change interventions.

Value-Based Care and Anesthesiology in the USA.

Value-based care, prioritizing patient outcomes over service volume, is steering a transformative course in anesthesiology in the United States. With the rise of this patient-centric approach, anesthesiologists are adopting dynamic roles to meet the demands of medical institutions, insurers, and patients for high-quality, cost-effective care. The urgency for this transition is accentuated by persistent challenges in reducing postoperative mortality rates and surgical complications, further spotlighted by the coronvirus disease 2019 (COVID-19) pandemic. Anesthesiologists engage in preoperative optimization, personalized care delivery, and evidence-based practices, bolstering their influence in the perioperative environment. Their collaboration with perioperative stakeholders propels the shift toward a value-driven healthcare landscape. This review analyzes the implementation of value-based care in American anesthesiology, assesses the significance of technology in enhancing its delivery, and outlines potential strategies for improving its application.

Intraoperative Fraction of Inspired Oxygen and Lung Injury in Coronary Artery Bypass Grafting: Study Protocol for a Randomised Controlled Trial.

OBJECTIVE: Postoperative pulmonary complications are a series of disorders that can contribute to respiratory distress and prolonged mechanical ventilation postoperatively. We hypothesise that a liberal oxygenation strategy during cardiac surgery leads to a higher incidence of postoperative pulmonary complications than a restrictive oxygenation strategy. METHODS: This study is a prospective, observer-blinded, centrally randomised and controlled, international multicentre clinical trial. RESULTS: After obtaining a written informed consent, 200 adult patients undergoing coronary artery bypass grafting will be enrolled and randomised to receive either restrictive or liberal oxygenation perioperatively. The liberal oxygenation group will receive 1.0 fraction of inspired oxygen throughout the intraoperative period, including during cardiopulmonary bypass. The restrictive oxygenation group will receive the lowest fraction of inspired oxygen required to maintain arterial partial pressure of oxygen between 100 and 150 mmHg during cardiopulmonary bypass and a pulse oximetry reading of 95% or greater intraoperatively, but no less than 0.3 and not higher than 0.80 (other than induction and when the oxygenation goals cannot be reached). When patients are transferred to the intensive care unit, all patients will receive an initial fraction of inspired oxygen of 0.5, and then fraction of inspired oxygen will be titrated to maintain a pulse oximetry reading of 95% or greater until extubation. The lowest postoperative arterial partial pressure of oxygen/fraction of inspired oxygen within 48 hours of intensive care unit admission will be the primary outcome. Postoperative pulmonary complications, length of mechanical ventilation, intensive care unit stay, hospital stay, and 7-day mortality after cardiac surgery will be analysed as secondary outcomes. CONCLUSION: This is one of the first randomised controlled observer-blinded trials that prospectively evaluates the influence of higher inspired oxygen fractions on early postoperative respiratory and oxygenation outcomes in cardiac surgery patients using cardiopulmonary bypass.

Traumatic hemorrhage and chain of survival.

Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.

Meta-analysis of Traditional Chinese Medicine Lianhua Qingwen in the Treatment of Coronavirus Disease 2019.

The rapid global spread of Coronavirus disease 2019 (COVID-19) has seriously threatened human life and health. Effects of traditional Chinese medicine, Lianhua Qingwen, combined with western medicine remains controversial for treatment of COVID-19. Evidence to support use of Lianhua Qingwen in COVID-19 is lacking. In this study, we systematically reviewed literature on the use of Lianhua Qingwen in COVID-19, and we performed meta-analysis to assess the effect of Lianhua Qingwen in COVID-19 management. We found that when combined with western medicine in the treatment of COVID-19 patients, Lianhua Qingwen may shorten duration of fever, reduce adverse events, decrease rate of conversion to severe disease, and improve symptom recovery and chest radiographic signs of pneumonia.

Echocardiography and Management for Cardiac Trauma.

Trauma is the number one cause of death among Americans between the ages of 1 and 46, costing >$670 billion a year. Blunt and penetrating trauma can lead to cardiac and aortic injuries, with the incidence of death varying upon the location of the damage. Among those who reach the hospital alive, many may survive if the hemorrhage and cardiovascular injuries are diagnosed and treated adequately in a timely fashion. Although echocardiography often is underused in the setting of cardiac trauma, it offers significant diagnosis and treatment potential because it is accessible in most settings, safe, relatively noninvasive, and can provide rapid and accurate trauma assessment in the hands of trained providers. This review article aims to analyze the pathophysiology of cardiac injuries in patients with trauma and the role of echocardiography for the accurate diagnosis of cardiac injury in trauma. This review, additionally, will offer a patient-centered, team-based, early management plan with a treatment algorithm to help improve the quality of care among these patients with cardiac trauma.

Electrocardiographic Features and Outcome: Correlations in 124 Hospitalized Patients With COVID-19 and Cardiovascular Events.

OBJECTIVES: Electrocardiographic (ECG) changes have been associated with coronavirus disease 2019 (COVID-19) severity. However, the progression of ECG findings in patients with COVID-19 has not been studied. The purpose of this study was to describe ECG features at different stages of COVID-19 cardiovascular (CV) events and to examine the effects of specific ECG parameters and cardiac-related biomarkers on clinical outcomes in COVID-19. DESIGN: Retrospective, cohort study. SETTING: Major tertiary-care medical centers and community hospitals in Louisville, KY. PARTICIPANTS: A total of 124 patients with COVID-19 and CV events during hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twelve-lead ECG parameters, biomarkers of cardiac injuries, and clinical outcomes were analyzed with Spearman correlation coefficients and Kruskal-Wallis 1-way analysis of variance. Atrial fibrillation/atrial flutter was more frequent on the ECG obtained at the time of the CV event when compared with admission ECG (9.5% v 26.9%; p = 0.007). Sinus tachycardia was higher in the last available hospital ECG than the CV event ECG (37.5% v 20.4%; p = 0.031). Admission ECG-corrected QT interval was significantly associated with admission troponin levels (R = 0.52; p < 0.001). The last available hospital ECG showed nonsurvivors had longer QRS duration than survivors (114.6 v 91.2 ms; p = 0.026), and higher heart rate was associated with longer intensive care unit length of stay (Spearman ρ = 0.339; p = 0.032). CONCLUSIONS: In hospitalized patients with COVID-19 and CV events, ECGs at various stages of COVID-19 hospitalization showed significantly different features with dissimilar clinical outcome correlations.

Hyperoxia After Return of Spontaneous Circulation in Cardiac Arrest Patients.

Current guidelines emphasize the use of 100% oxygen during cardiopulmonary resuscitation after cardiac arrest. When patients are ventilated for variable periods after return of spontaneous circulation (ROSC), hyperoxia causes increased morbidity and mortality by overproduction of reactive oxygen species. Various patient, volunteer, and animal studies have shown the harmful effects of hyperoxia. This mini-review article aims to expand the potential clinical spectrum of hyperoxia on individual organ systems leading to organ dysfunction. A framework to achieve and maintain normoxia after ROSC is proposed. Despite the harmful considerations of hyperoxia in critically ill patients, additional safety studies including dose-effect, level and onset of the reactive oxygen species effect, and safe hyperoxia applicability period after ROSC, need to be performed in various animal and human models to further elucidate the role of oxygen therapy after cardiac arrest.

Model driven design for twin screw granulation using mechanistic-based population balance model.

This paper presents a generic framework of Model Driven Design (MDD) with its application for a twin screw granulation process using a mechanistic-based population balance model (PBM). The process kernels including nucleation, breakage, layering and consolidation are defined in the PBM. A recently developed breakage kernel is used with key physics incorporated in the model formulation. Prior to granulation experiments, sensitivity analysis of PBM parameters is performed to investigate the variation of model outputs given the input parameter variance. The significance of liquid to solid ratio (L/S ratio), nucleation and breakage parameters is identified by sensitivity analysis. The sensitivity analysis dramatically reduces the number of fitting parameters in PBM and only nine granulation experiments are required for model calibration and validation. A model validation flowchart is proposed to elucidate the evolution of kinetic rate parameters associated with L/S ratio and screw element geometry. The presented MDD framework for sensitivity analysis, parameter estimation, model verification and validation can be generalized and applied for any particulate process.

Exploring the relationship between mastitis risk perceptions and farmers' readiness to engage in milk recording.

The need to move towards Selective Dry Cow Therapy (SDCT) has become increasingly pertinent as a means to reduce the use of antibiotics in the dairy sector. With the EU 2022 ban on prophylactic antibiotics at drying off, practices on some farms will need to drastically change. In Ireland, one particular challenge to the sector-wide transition to SDCT is the lack of widespread uptake of milk recording across dairy farms, a decision support tool which can support mastitis control and help identify cows to select for SDCT. The current study examined readiness to engage in milk recording amongst Irish dairy farmers, and specifically investigated the role of mastitis risk perceptions in shaping farmers' readiness. The study explores the multifaceted nature of risk perception as a construct shaping farmers' attitudes. An online survey was carried out with 197 Irish dairy farmers exploring their attitudes towards mastitis and milk recording. A cluster analysis classified farmers according to their mastitis risk perceptions, with 3 segments identified with differing risk perception profiles. Elevated mastitis risk perceptions were linked to an increased readiness to milk record. However, this relationship was not universal across all farmers. One segment of farmers in the current study maintain low mastitis risk perceptions and remain unmotivated to engage in milk recording. The study concludes that targeted risk communication strategies related to mastitis and milk recording are needed to encourage the move towards SDCT and reduced AMR. Results suggest that the types of risk communication strategies - message framing and two-way risk communication - should reflect farmers' types of mastitis risk perceptions to have the most effective impact on milk recording uptake.

Implementing an electronic hand hygiene system improved compliance in the intensive care unit.

BACKGROUND: Hand hygiene (HH) compliance is low and difficult to improve among health care workers. We aim to validate an electronic HH system and assess the impact of this system on HH compliance and quality changes over time at both group and individual levels. METHODS: An automated electronic HH system was installed in a 10-bed surgical intensive care unit. RESULTS: The full HH compliance rate increased significantly from 8.4% in week 1 to 20.5% in week 16 with week 10 being the highest (27.4%). The partial compliance rate maintained relative consistency between 13.2% and 20.0%. The combined compliance rate (full compliance rate + partial compliance rate) increased from 23.5% in week 1 to 34.6% in week 16 with week 10 being the highest (41.4%). DISCUSSION: We found significant variations among providers in terms of HH opportunities per shift, full compliance, partial compliance and combined compliance rates. The average duration of hand rubbing over time in partial compliance occurrences did not change significantly over time. CONCLUSIONS: A sensor-based platform with automated HH compliance and quality monitoring, real time feedback and comprehensive individual level analysis, improved providers' HH compliance in an intensive care unit. There were significant variations among individual providers.

A specific low-density neutrophil population correlates with hypercoagulation and disease severity in hospitalized COVID-19 patients.

SARS coronavirus 2 (SARS-CoV-2) is a novel viral pathogen that causes a clinical disease called coronavirus disease 2019 (COVID-19). Although most COVID-19 cases are asymptomatic or involve mild upper respiratory tract symptoms, a significant number of patients develop severe or critical disease. Patients with severe COVID-19 commonly present with viral pneumonia that may progress to life-threatening acute respiratory distress syndrome (ARDS). Patients with COVID-19 are also predisposed to venous and arterial thromboses that are associated with a poorer prognosis. The present study identified the emergence of a low-density inflammatory neutrophil (LDN) population expressing intermediate levels of CD16 (CD16Int) in patients with COVID-19. These cells demonstrated proinflammatory gene signatures, activated platelets, spontaneously formed neutrophil extracellular traps, and enhanced phagocytic capacity and cytokine production. Strikingly, CD16Int neutrophils were also the major immune cells within the bronchoalveolar lavage fluid, exhibiting increased CXCR3 but loss of CD44 and CD38 expression. The percentage of circulating CD16Int LDNs was associated with D-dimer, ferritin, and systemic IL-6 and TNF-α levels and changed over time with altered disease status. Our data suggest that the CD16Int LDN subset contributes to COVID-19-associated coagulopathy, systemic inflammation, and ARDS. The frequency of that LDN subset in the circulation could serve as an adjunct clinical marker to monitor disease status and progression.

Outcomes and Risk Factors for Cardiovascular Events in Hospitalized COVID-19 Patients.

OBJECTIVE: To analyze outcomes and risk factors of cardiovascular events in a metropolitan coronavirus disease 2019 (COVID-19) database, and to perform a subgroup analysis in African American populations to determine whether outcomes and risk factors are influenced by race. DESIGN: Retrospective cohort analysis from March 9, 2020 to June 20, 2020. SETTING: Population-based study in Louisville, KY, USA. PARTICIPANTS: Seven hundred adult inpatients hospitalized with COVID-19. INTERVENTIONS: N/A. MEASUREMENTS AND MAIN RESULTS: This cohort consisted of 126 patients (18%) with cardiovascular events and 574 patients without cardiovascular events. Patients with cardiovascular events had a much higher mortality rate than those without cardiovascular events (45.2% v 8.7%, p < 0.001). There was no difference between African American and white patients regarding mortality (43.9% v 46.3%, p = 1) and length of stay for survivors (11 days v 9.5 days, p = 0.301). Multiple logistics regression analysis suggested that male, race, lower SaO2/FIO2, higher serum potassium, lower serum albumin, and number of cardiovascular comorbidities were highly associated with the occurrence of cardiovascular events in COVID-19 patients. Lower serum albumin and neoplastic and/or immune-compromised diseases were highly associated with cardiovascular events for African American COVID-19 patients. SaO2/FIO2 ratio and cardiovascular comorbidity count were significantly associated with cardiovascular events in white patients. CONCLUSIONS: Cardiovascular events were prevalent and associated with worse outcomes in hospitalized patients with COVID-19. Outcomes of cardiovascular events in African American and white COVID-19 patients were similar after propensity score matching analysis. There were common and unique risk factors for cardiovascular events in African American COVID-19 patients when compared with white patients.

Anticoagulation Management in Severe Coronavirus Disease 2019 Patients on Extracorporeal Membrane Oxygenation.

OBJECTIVE: To explore special coagulation characteristics and anticoagulation management in extracorporeal membrane oxygenation (ECMO)-assisted patients with coronavirus disease 2019 (COVID-19). DESIGN: Single-center, retrospective observation of a series of patients. PARTICIPANTS: Laboratory-confirmed severe COVID-19 patients who received venovenous ECMO support from January 20-May 20, 2020. INTERVENTIONS: This study analyzed the anticoagulation management and monitoring strategies, bleeding complications, and thrombotic events during ECMO support. MEASUREMENTS AND MAIN RESULTS: Eight of 667 confirmed COVID-19 patients received venovenous ECMO and had an elevated D-dimer level before and during ECMO support. An ECMO circuit pack (oxygenator and tubing) was replaced a total of 13 times in all 8 patients, and coagulation-related complications included oxygenator thrombosis (7/8), tracheal hemorrhage (5/8), oronasal hemorrhage (3/8), thoracic hemorrhage (3/8), bleeding at puncture sites (4/8), and cannulation site hemorrhage (2/8). CONCLUSIONS: Hypercoagulability and secondary hyperfibrinolysis during ECMO support in COVID-19 patients are common and possibly increase the propensity for thrombotic events and failure of the oxygenator. Currently, there is not enough evidence to support a more aggressive anticoagulation strategy.

Artificial Intelligence in Echocardiography for Anesthesiologists.

Echocardiography is a unique diagnostic tool for intraoperative monitoring and assessment of patients with cardiovascular diseases. However, there are high levels of interoperator variations in echocardiography interpretations that could lead to inaccurate diagnosis and incorrect treatment. Furthermore, anesthesiologists are faced with the additional challenge to interpret echocardiography and make decisions in a limited timeframe from these complex data. The need for an automated, less operator-dependent process that enhances speed and accuracy of echocardiography analysis is crucial for anesthesiologists. Artificial intelligence is playing an increasingly important role in the medical field and could help anesthesiologists analyze complex echocardiographic data while adding increased accuracy and consistency to interpretation. This review aims to summarize practical use of artificial intelligence in echocardiography and discusses potential limitations and challenges in the future for anesthesiologists.